Knee Pain: Looking to the Foot for Answers

Knee pain is and will forever be the jumping off point for your family, friends, and even strangers to segue into their uneducated medical opinion regarding the irreversible damage at your knees. Despite countless research studies finding no connection between running, mileage, and symptomatic knee osteoarthritis, you’ll never hear the end of it. Even worse, one condition of the knee is so common in runner’s its actual garnered the name, “Runner’s Knee.” At the top of every runner’s ‘things I hate to talk about’ list are injuries… especially with family… and even more so with members who have that “I told you so” attitude.

Despite the fact that most knee injuries for runners are non-arthritic, it seems that all of them are lumped together. Runner’s Knee, a condition that results in compression load intolerance under your knee cap, has nothing to do with degenerative changes of the joint. It’s no secret that we need to look elsewhere when evaluating knee pain. Clinicians and enthusiasts alike have all jumped on the “strengthen your hips” bandwagon. For good reason, too. We consistent tell patients that if your big, strong neighbors up top (your hips) aren’t producing force and absorbing shock, the force needs to come from and go somewhere. This will be enough for some runners. For others it’s just another attempt to try and understand why their knees hurt.

Don’t get me wrong, exploring hip strength is a great place to start, but what if you’ve traveled that road and found no relief? Luckily, you still have options. Just as we look to the hips for the answer, we need to look below. The foot and ankle is often overshadowed with hip strength in both literature and the clinic. Tight calf muscles or a tight ankle joint will effectively transfer their shock absorbing properties up the chain. Hello knee.

The inability for the shin to glide over a fixed foot will ultimately be problematic. As our foot glides into dorsiflexion our elastic muscles of our calf, predominately soleus muscle, will absorb that force. Stiffness or tightness will cause early heel rise, diminished shock absorption, and the transfer of force to the knee.

How do I check my ankle flexibility?

For those of you have already pulled up on your toes to self asses flexibility, stop it. You need to know that you have two muscles in your calf and only one of them is worth assessing in this instance. Secondly, pulling up on your toes is open chain, meaning your foot is off the ground. You’ll want to assess your flexibility with your foot fixed to the ground (closed chain).

Start by standing perfectly straight with your feet shoulder width apart and facing straight ahead. Squat straight to the floor as you allow your knees to drop out over your toes. Your heels MUST stay flat and you MUST keep your shoulders, hips and ankles aligned. You’re also cheating if you allow your knees to fall inwards.

Normal: Your knees should drive out to your big toe or even an inch beyond. You’ll likely feel a stretch in your lower calf muscle, the soleus.

Abnormal: Yep, I said you’re abnormal (don’t worry I am too). If you’re heels rise too early, you lose. If you feel pinching in the front of the ankle, you lose. If you cannot keep your shoulders, hips, and ankles in a perfect vertical line, you lose. If you can’t keep your heels flat and drive your knees well beyond your toes, you lose.

Each abnormal finding means a different issue. Here are the likely scenarios:

Early Heel Rise

Your muscles don’t allow for enough motion. Early heel rise is likely happening while you run, transferring force into the knee.

Pinching in the Front of the Ankle

Excessive Range of Motion

Congrats! You’re like me. For some, you’re too flexible. Your ankle doesn’t have a buttress to stop movement. In these instances more strength is indicated.

Just remember, when your knee, foot, or hips hurt, the source of the pain is likely elsewhere. To sit and hammer on a painful bodypart without looking to get the neighbors (joint above and below) involved is ill-advised.

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Steve Gonser PT, DPT

Steve Gonser graduated with his Doctorate in Physical Therapy from Daemen College, instantly applying his knowledge of human movement and functional anatomy to his passion for running. Steve is a 2x Ironman, including a 10:41 finish in Lake Placid and a Sub-3 hour marathoner.